Personal Information

First NameSocial Security NumberDo you plan to file a federal income tax return NEXT YEAR?
You can still apply for coverage even if you don't file a federal income tax return.YesNoa. Will you file jointly with a spouse?YesNoIf yes, write name of spouse: If yes, provide Social Security Number of spouse:b. Will you claim any dependents on your tax return?YesNoIf yes, list name(s) and Social Security Number(s) of dependents:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

Name:SSN:

c. Will you be claimed as a dependent on someone's tax return?YesNoIf yes, please list the name of the tax filer:
How are you related to the tax filer?

Spouse's Job:

If self-employed, answer the following two questions:a. Type of work:b. How much net income (profits once business expenses are paid)
will you get from this self-employment this month?
How much?

Other Income

Fill in all that apply, and give the amount and how often you get it.NOTE:You don't need to tell us about income from child support, veteran's payments, or Supplemental Security Income (SSI).Unemployment
How much?
How often?Pension
How much?
How often?Social Security
How much?
How often?Retirement accounts
How much?
How often?

Deductions

Fill in all that apply, and give the amount and how often you pay it. If you pay for certain things that can be deducted on a federal income tax return,
telling us about them could make the cost of health coverage a little lower.NOTE: You shouldn't include child support that you pay, or a cost already considered in your answer to net self-employment.Alimony paid
How much?
How often?Student loan interest
How much?
How often?Your total income this year
How much?Your total income next year (if you think it will be different)
How much?

Your Family's Health Coverage

Is anyone listed on this application offered health coverage from a job?
Check yes even if the coverage is from someone else's job, like a parent or spouse, even if they don't accept the coverage.YesNoIs anyone enrolled in health coverage now?YesNo